Provider Demographics
NPI:1588846083
Name:PRO CARE MEDICAL SUPPLIES, INC.
Entity Type:Organization
Organization Name:PRO CARE MEDICAL SUPPLIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RENAT
Authorized Official - Middle Name:
Authorized Official - Last Name:PAPSHUOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-956-0704
Mailing Address - Street 1:1614 VICTORY BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-2946
Mailing Address - Country:US
Mailing Address - Phone:818-956-0704
Mailing Address - Fax:818-956-0714
Practice Address - Street 1:1614 VICTORY BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91201-2946
Practice Address - Country:US
Practice Address - Phone:818-956-0704
Practice Address - Fax:818-956-0714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPZUC-20070626332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6241830001Medicare NSC